Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists, interested bystanders are also welcome. A place to talk; no one has to listen.

Tuesday, May 31, 2011

Daniel Carlat on Antipsychotic Medications for Agitation in Patients with Dementia

Lately, it seems like all the press about psychiatry in The New York Times is bad. We don't talk to our patients, we over-medicate them all from the children to the elderly, we all get bribes from drug companies. It's not that I don't think that these things don't happen, it's just that I don't like the sensational tones, and the one-sided nature of the presentation of psychiatrists as bad, the generalizations that it's "everyone," and the use of information taken out of context to make our practitioners look bad.

More than half of the antipsychotics paid for by the federal Medicare program in the first half of 2007 were “erroneous,” the audit found, costing the program $116 million for those six months.

“Government, taxpayers, nursing home residents as well as their families and caregivers should be outraged and seek solutions,” Daniel R. Levinson, inspector general of the Department of Health and Human Services, wrote in announcing the audit results.

Mr. Levinson apparently feels the government should collect information on diagnoses so correct prescribing can be assessed.

But antipsychotics are most effective drug for calming agitation in dementia, he writes

Carlat: No drugs are FDA-approved for this agitation, a terrible condition

Carlat writes:

But in this particular case, the Office of the Inspector General has it wrong, and Levinson's statements on behalf of Health and Human Services reflect an astonishingly poor understanding of the workings of medical care in general and psychiatric care in particular.

The unfortunate fact is that no medications are FDA-approved for the agitation of dementia, and yet the condition is common.

Although it's true that a prescription for antipsychotics to treat agitation in dementia is "off-label," this hardly means they are ineffective or that Medicare claims for these drugs are "erroneous." In fact, large placebo-controlled trials have shown that antipsychotics are the most effective medications for the agitation that often bedevils patients with dementia.

When these drugs are successful, they soothe the inner turmoil that makes life intolerable for these patients, improving their quality of life dramatically.

11 comments:

Sideways Shrink
said...

I agree with Carlat. Having treated agitated dementia symptoms successfully with anti-psychotics, I continued to do so even after data came out in 2005(?) about atypicals increasing the rate of lethal CVAs in demented patients by 1.6%-2.3%. My only problem with the article was that Carlat seemed to write the article not for CNN and but for the Washington Post Healthcare OpEd page. He is very, very clever, but the basic idea of using medications off label can be a nuanced idea for a general reader. Carlat's efforts to reassure the reader that he is critical of pharmaceutical companies only complicated the explanation of why psychiatrists would use off label anti-psychotic medications designed for "crazy" people to "shut up grandma". I am almost ashamed of myself for saying this, but writing for the actual audience is helpful. Or perhaps it simply took too many paragraphs for Carlat to get to his points. But if the Fed further audit the prescribing of anti-psychotics, it will be all about cost: because with the exception of risperidone, they are all still on brand. It will have nothing to do with on or off label use of medications. No one is going to investigate whether they are using various generics off label for this or that. Who is kidding who?

If I were bound to prescribe medications according to their labeled indications only, there would be precious in the materia medica little available to me!

I have some questions about the use of anti-psychotics in dementia: I'm not surprised that these drugs sedate demented people. My question is do they ever FAIL to sedate demented people? And if so, could the reason for "treatment failure" have to do with insufficient dosing?

I'm curious to know if any of the commenters here have prescribed anti-psychotics to demented people without the consent of the person's proxy?

Finally, Cui Bono? (who benefits?) Are we treating the demented person, or keeping her quiet for the benefit of the staff?

At least one of the state Medicaid P&T committees (they make decisions about which meds to pay for based on cost and clinical issues) removed Zyprexa solely due to its metabolic side effects. It also happened to be the most costly drug on the list. I'm curious what will happen to Zyprexa when it goes generic at the end of this year.

I have prescribed atypical antipsychotics (very low doses) to elderly patients with dementia, for many of the reasons outlined by Carlat in his article.

However, virtually without fail, these drugs end up being given far more frequently than how I had anticipated their being used based on my original discussion with the caregiver. To answer Rob's question, it's almost always for the benefit of the staff.

What does determine what a drug is 'on label/approved' for? Is this determined by the drug companies and what the drug trials are aimed at? So for a drug to be approved for an indication drug trials need to be carried out, and then an insurance company needs to approve that particular use of this drug?

As someone with 'psychotic depression' in Australia I don't think there ARE any atypicals that are on our PBS for uni-polar depression. So because I don't have Bipolar or Schizophrenia, I theoretically have the choice of 1st gen generics or paying through the nose. (my doc rocks and puts it through anyway).

Also a side note, I have 20 min appointments with my psych every couple of months, and they are primarily for med management. And if I ever did go 'crazy' again, or I wanted a longer appointment I'd just book it in. The difference is, that psychiatrist appointments are not covered by almost all insurance policies here, so I have to pay for it.

To all those people who complain about their insurance denying them longer appointments or the ability to change doctors. Has it ever occurred to you that you could just foot the bill yourself?Yeah, it would be a lot of money (I pay ~$300/hour here) but it's your health people! Have some self efficacy and do what is right for you, and stop bloody well complaining!

Sorry. I may have just revealed that I have no debts, and no real responsibilities. I keep on thinking that 'cause I lived on next-to-nothing as a student (MUCH less than the pension) and still paid for doc appts, that others should be able to do so too.Blissfully unaware that everyone else has other priorities.

Clinical trials. It's illegal for pharma to promote a drug for an off label indication, however they do it with regularity because it pays to do so - the most they'll face is a large fine and the money they've made from their illegal activity is significantly more than any fine they'll pay.